REPUBLIC OF THE PHILIPPINES)

________________________) S.S.

AFFIDAVIT OF SELF-ADJUDICATION

I, ______________________________ (surviving heir), of legal age, ____________ (citizenship).

_____________ (civil status) and residing at _________________________________________________

Hereby freely and voluntarily declare and state THAT:

1. I am the only legal heir of the deceased __________________________ (name of deceased)

who died on _______________________ at _______________________ (the “Deceased”).

2. The Deceased died intestate without leaving any Last Will and Testament and without any
outstanding debts:

3. The Deceased left the following property/ies, to wit:

(list of properties left by the deceased which should include the BDO account)

4. Pursuant to Section 1 of Rule 74 of the revised Rules of Court of the Philippines, I hereby
adjudicate unto myself the above-described property/ies by means of this Affidavit.

IN WITNESS WHEREOF, I have set my hand this ________ day of __________________, 20 ____
at ______________________________, Philippines.

___________________________

(SURVIVING HEIR)

SUBSCRIBED AND SWORN to before me this ___________ day of ______________, 20 ____ at

____________________________; affiant exhibiting to me his/her ______________________________

(Competent Evidence of Identity) issued on ________________________at _______________________

and valid until _____________________________________.

Doc. No. ______________ ;

Page No. ______________;

Book No. ______________;

Series of 20 ____________.